INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2006 to May 18, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 15, 2006.
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Plan of Correction
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705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
The organization failed to provide documentation of a Labor and Industry occupancy certificate or local equivalent by May 18, 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
In one of three files reviewed on May 17, 2006 the organization failed to provide documentation of staff instruction in regard to fire extinguisher use within seven day of employment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
In one of three files reviewed on May 17, 2006 the organization failed to provide documentation of staff instruction in regard to performance of assigned task during emergencies within seven day of employment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The organization failed to produce an annual report with public availability since the 2003/2004 fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
The organization failed to produce an annual report with activities and accomplishments since the 2003/2004 fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
The organization failed to produce an annual report with financial statement of income and expenses since the 2003/2004 fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
The organization failed to produce an annual report with a statement disclosing the names of officers and directors since the 2003/2004 fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
The organization failed to provide documentation of an annual performance evaluation in one of three files reviewed on May 17, 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
The organization failed to provide documentation of an annual performance evaluation, by written copy, in one of three files reviewed on May 17, 2006
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
In two of four active clinical files reviewed on May 18, 2006, the psychosocial evaluation failed to provide documentation of the counselors impression and a client composite statement.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
In four of eight clinical files reviewed on May 18, 2006, the progress notes failed to document clinical planning.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |